Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(3):12704 1 ORIGINAL PAPER tries (1, 2). This procedure can be performed by patients, non-professionals, or medical personnel and can present severe consequences in cases of complications (3), including penile deformity, skin necrosis, limited erection due to pressure, and pain during sex (4). The definitive therapy is to remove the entire skin and subcutaneous tissue and resurface the penile shaft (5). The technique can be single-staged (simple excision and primary closure, bilateral scrotal flap, one-sheet spiraling full-thickness skin graft, scrotal tunnel + inverted V inci- sion and anastomosis inverted Y technique), or multi- staged (6-8). Erectile function is assessed by measuring erection hard- ness using the erection hardness score (EHS), which pro- vides specific and readily monitored results (9). In this study, we report our experience in performing treatment on penile paraffinoma patients using the scrotal tunnel + ventral inverted V incision + anastomosis invert- ed Y technique, along with the esthetics and functional outcome of the procedure. MATERIALS AND METHODS We performed a single-center retrospective descriptive study using data collected from January 2013 to December 2023 from patients who underwent single-stage scrotal tunnel + ventral inverted V-incision and anastomosis inverted Y-shape procedures (Figure 1). Figure 2 provides a conceptual illustration of the technique. Data on the chief complaint, reason for the injection, type of fluid injected, duration of surgery, duration of hospi- talization, length of follow-up, and results after surgery were collected. The inclusion criteria were as follows: [1] new patient and [2] penile paraffinoma performed in a single stage. Exclusion criteria were [1] penile paraffinoma that affect- ed the skin of the penis and greater than half of the skin of the scrotum, [2] presence of malignancy, and [3] penile paraffinoma coexisting with diabetes mellitus. Introduction and objective: Penis enlarge- ment through substance injection is common in many countries of Southeast Asia and Eastern Europe. The definitive therapy involves removing the entire skin and the sub- cutaneous tissue and resurfacing the penile shaft via a single- stage or multi-staged procedure. This study aimed to report the functional outcome and esthetics of treating penile paraffinoma patients using the scrotal tunnel + ventral inverted V incision + anastomosis inverted Y technique. Materials and methods: This study was a single-center retro- spective descriptive analysis of patients who underwent one- stage scrotal tunnel + ventral inverted V incision and inverted Y-shaped anastomosis procedures from January 2013 to December 2023. The following data were collected: chief com- plaint, reason for the injection, type of fluid injected, duration of surgery, duration of hospitalization, length of follow-up, and results after surgery. Results: Of the 32 patients included in the study, 78% injected liquids in the form of oil and the goal of the majority of patients was penis enlargement (71%). The average age was 36.84 years, and the main complaint was pain in the penis during erection (53%). The average operation time was 130 minutes, hospitalization duration was 2.21 days, primary wound healing was 91%, patient satisfaction level was 97%, and Scale 4 erec- tion hardness was 91%. Conclusions: One-stage surgery for penile paraffinoma produced promising results when the granuloma was limited to the penis and healthy scrotal skin was available to cover the penis. KEY WORDS: Penile paraffinoma; Surgery; One stage; Scrotal flap; Functional outcome. Submitted 2 June 2024; Accepted 11 July 2024 INTRODUCTION Penis enlargement through the injection of substances (paraffin, oil, cod liver oil, petroleum jelly, silicone, methacrylates, hyaluronic acid, or collagen patches) is common in Southeast Asian and Eastern European coun- Functional outcome of the one-stage scrotal tunnel + ventral inverted V incision + inverted Y anastomosis technique to treat penile paraffinoma: A single center retrospective study Muhammad Asykar Palinrungi 1, Syakri Syahrir 2, Syarif 1, Andhini L.R. Palinrungi 3, Muhammad Faruk 4 1 Department of Urology, Faculty of Medicine, Hasanuddin University - Hasanuddin University Hospital, Makassar, South Sulawesi, Indonesia; 2 Department of Urology, Faculty of Medicine, Hasanuddin University - Dr. Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi, Indonesia; 3 Department of Surgery, Akademis Jaury Jusuf Putra Hospital, Makassar, South Sulawesi, Indonesia; 4 Department of Surgery, Faculty of Medicine, Hasanuddin University - Hasanuddin University Hospital, Makassar, South Sulawesi, Indonesia. DOI: 10.4081/aiua.2024.12704 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(3):12704 M. Asykar Palinrungi, S. Syahrir, Syarif, et al. 2 Figure 1. Step-by-step representation of the operative stage. One- stage surgical excision steps with scrotal tunnel + ventral inverted V-incision and anastomosis inverted Y-shape. A) After the skin of the penis is removed, B) the creation of the tunneling exit hole, C) after the penis is passed under the skin and the glans protrudes from the prepared hole (penile scrotal invagination), D) appearance after suturing, E) inverted V-incision, and F) after suturing into inverted Y-shape. Figure 2. A conceptual illustration of the one-stage surgical excision steps with scrotal tunnel + ventral inverted V-incision and inverted Y-shaped anastomosis. A) Paraffinoma in the shaft of the penis, B) excision of the entire paraffinoma in the penile shaft, C) naked penile shaft after the skin is excised, D) measurement of the scrotal tunnel for scrotal flap creation, E) creation of a hole in the scrotum, F) insertion of the penis into the scrotum hole to cover the penis with the skin of the scrotum (penile scrotal invagination), G) inverted V-incision on the ventral penis, and H) inverted Y-shaped suture. Archivio Italiano di Urologia e Andrologia 2024; 96(3):12704 3 Technique to treat penile paraffinoma This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Informed consent was obtained from all patients and this study was approved by the Ethics Committee of Hasanuddin University, Makassar, Indonesia (no. 304/UN4.6.4.5.31/PP36/2024) with protocol no. UH24040277. The five-grade EHS was used to assess erection rigidity [Grade 0 (no enlargement of the penis), Grade 1 (penis enlarges but does not become firm), Grade 2 (penis is hard, but not hard enough to penetrate), Grade 3 (penis is hard enough for penetration but not completely hard), and Grade 4 (penis is completely stiff and firm)]. A score of two or less was considered an abnormal EHS (10). RESULTS The 32 patients included in this study had an average age of 36.84 years and an average length of hospital stay of 2.21 days. Most patients had a history of silicone, oil, or paraffin injections with the main aim of enlarging the penis. The characteristics of the data are listed in Table 1. DISCUSSION The outcomes we obtained from the 32 patients were positive, whereby 29 patients recovered completely, 2 patients experienced wound infection, and 1 patient pre- sented contractures, which we successfully excised sever- al months later. No erection problems were noted accord- ing to the EHS, and no sexual activity issues were report- ed after surgery. A one-stage penile paraffinoma excision is faster and easier than a two-stage procedure (requires only one operation, which generally reduces the time for recovery and degree of pain). In addition, this method is more cost-effective (the cost is usually more affordable than a two-stage surgery), has less risk of complications (fewer incisions and tissue manipulations), and allows for a thorough evaluation (the surgeon can perform a com- prehensive assessment of the penile tissue during surgery to evaluate any other problems that need to be addressed). The disadvantages of the one-stage technique are long recovery times (despite only requiring one sur- gery), swelling and bruising (swelling and bruising are common side effects after surgery), infection (infection is a minor but serious risk after any surgery), nerve damage (nerve damage may occur, which can cause numbness or tingling of the penis), and penile deformity (particularly when the silicone implant is large or has been in place for many years). Granulomatous reactions resulting from the injection of a foreign body can accumulate in parts of the penis or spread to the entire penile shaft, supra-pubic area, and scrotum (11, 12). When complications occur, the entire foreign object and related skin should be removed to pre- vent the recurrence or graft loss that can occur if some residue remains (13). Simple excision and primary sutur- ing may be performed in selected cases (14); however, if the penile paraffinoma involves the entire penile shaft without extension to the suprapubic area (84% of the cases in this study) or a small amount of the scrotal area (3% of our cases), then the treatment therapy should involve a radical excision of the fibrotic tissue and the associated skin and the use of scrotal skin to close the open area. The skin of the scrotum has high elasticity, which makes it suitable for covering the penis, despite the presence of hair. Most of the surgeries are successful without any complications, and the reconstructed penis has an imme- diate post-operative tactile sensibility (1, 2, 6, 13). The two-stage procedure for paraffinoma involves expos- ing the penis and inserting it into the previously created scrotal tunnel while leaving the glans exposed for urina- tion. After a few weeks, the penis is removed from the scrotum (13). In all our cases, we performed a single-stage scrotal tunnel and inverted V incision + inverted Y anasto- mosis after removing all parts of the penile skin along with the underlying granulomatous tissue (Figure 1). This action is possible because sufficient skin in the scrotum is available to cover the penis. The average time required for this procedure is 130 minutes, while the average length of hospital stay is 2.21 days and the average follow-up is 3.4 months. Lumbiganon et al. found no significant difference in surgi- cal wound infection, wound dehiscence, or reoperation rate in the one-stage group compared to the two-stage Table 1. Clinical characteristics of patients. Characteristic N (%) Patient (n) 32 Mean age (y) 36.84 Reason for injection (n) - enlarge the penis 23 (71) - increase self-confidence 5 (16) - satisfy sexual partner 4 (13) Foreign body type (n) - vaseline 3 (9) - oil 25 (78) - paraffin 4 (13) Location - the entire shaft of the penis 27 (84) - part of the shaft of the penis 4 (13) - the entire shaft of the penis + a small part of the scrotum 1 (3) Reason for treatment - pain during erection 17 (53) - chronic wound 5 (16) - difficulty during sex 7 (22) - phimosis 2 (6) - penile deformity 1 (3) Mean operation time (min) 130 Mean length of stay (d) 2.21 Mean follow-up period (mo) 3.4 Results after operation (n) - good healing 29 (91) - wound infection 2 (6) - scar contracture 1 (3) Satisfaction status - satisfied 31 (97) - not satisfied 1 (3) EHS - 3 3 (9) - 4 29 (91) EHS: Erection Hardness Score. Archivio Italiano di Urologia e Andrologia 2024; 96(3):12704 M. Asykar Palinrungi, S. Syahrir, Syarif, et al. 4 group; however, the two-stage group had a longer length of stay and lower complication rate. Therefore, these two techniques can be considered for reconstruction in penile paraffinoma cases (15). In addition, Dellis et al. recom- mended one-stage surgery after the procedure was per- formed on 10 patients with safe and effective results (16). This study had several limitations. As a retrospective cohort study, it was subject to inherent selection and information biases. In addition, the study was conducted at a single center, which may limit the generalizability of the findings. Further multicenter, prospective studies are required to validate these results and confirm whether the one-stage scrotal tunnel + ventral inverted V incision + inverted Y anastomosis technique is safe and effective and can provide the appropriate functional and esthetic out- come post-surgery. CONCLUSIONS Single-stage surgery on penile paraffinoma can be effec- tive when the granuloma is limited to the penis and healthy scrotal skin is available to cover the penis. ACKNOWLEDGMENTS We acknowledge Ashy Amelia Arista for her help in pro- viding us with the conceptual illustration of the one-stage surgical excision steps for this study. REFERENCES 1. Mahadewa AW, Marinta Y, Nugraha P, Lukman K. Candlenut oil- induced sclerosing lipogranuloma of the penis: A case report. Int J Surg Case Rep. 2023; 110:108673. 2. Marín-Martínez FM, Guzmán Martínez-Valls PL, Dekalo S, et al. Aesthetic and Functional Results after Single- and Two-Stage Resection and Reconstruction of Penile Paraffinomas - Experience from Two Tertiary Centers and a Surgical Management Algorithm. Urology. 2023; 171:227-35. 3. Dellis AE, Nastos K, Mastorakos D, et al. Minimal surgical man- agement of penile paraffinoma after subcutaneous penile paraffin injection. Arab J Urol. 2017; 15:387-90. 4. 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Correspondence Muhammad Asykar Palinrungi (Corresponding Author) apalinrungi@yahoo.com Department of Urology, Faculty of Medicine, Hasanuddin University – Hasanuddin University Hospital, Makassar, South Sulawesi, Indonesia Jalan Perintis Kemerdekaan KM 11, Makassar, 90245, South Sulawesi, Indonesia Syakri Syahrir drsyakrisyahrir@gmail.com Department of Urology, Faculty of Medicine, Hasanuddin University – Dr. Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi, Indonesia Syarif syarifbakri@hotmail.com Department of Urology, Faculty of Medicine, Hasanuddin University – Hasanuddin University Hospital, Makassar, South Sulawesi, Indonesia Andhini L. R. Palinrungi dnypalinrungi@gmail.com Department of Surgery, Akademis Jaury Jusuf Putra Hospital, Makassar, South Sulawesi, Indonesia Muhammad Faruk muhammadfaruk@unhas.ac.id Department of Surgery, Faculty of Medicine, Hasanuddin University – Hasanuddin University Hospital, Makassar, South Sulawesi, Indonesia Conflict of interest: The authors declare no potential conflict of interest.